New Jersey

As of July 1, 2011, there were 1,098,608 beneficiaries enrolled in the state’s Medicaid program, 853,645 of whom were enrolled four Medicaid-only MCOs (as of September 2014, five MCOs participate in the state’s Medicaid program).

Physical, behavioral, and oral health benefits are provided to Medicaid beneficiaries through the state’s Family Care managed care program. Outpatient substance abuse serves are carved out of managed care and provided on a fee-for-service basis.

In 2012, New Jersey received approval for a Section 1115 Demonstration that consolidated its existing managed care programs, as well as four existing home and community-based service waivers.

As of 2013, 782,311 individuals were eligible for New Jersey’s Early Periodic Screening, Diagnostic and Treatment Benefit (EPSDT). According to 416 data from 2013, the state achieved an EPSDT screening ratio of 90% and a participant ratio of 64%. 353,364 children received dental services of any kind, with 329,795 receiving preventive dental services.

New Jersey defaults to the federal definition of medical necessity for the EPSDT benefit. The state does not have a formal state-level medical necessity definition for Medicaid, deferring to clinical judgment and industry best practices. In discussing Medicaid-covered services, the New Jersey Administrative Code (N.J.A.C. 10:49-5.1) notes that:

“Any service limitations imposed will be consistent with the medical necessity of the patient’s condition as determined by the attending physician or other practitioner and in accordance with standards generally recognized by health professionals and promulgated through the New Jersey Medicaid program.”

New Jersey has in place a performance-based incentive program for managed care organizations (MCOs). MCOs earn back an amount withheld from their capitation payment based on performance on maternity care and prevention screening measures; the latter category includes a measure of the percentage of Medicaid enrollees aged 3-17 who have evidence of a body mass index percentile documentation.

MCOs must also report annually on a set of HEDIS performance measures that include:

Children receive behavioral health assessments as part of well-child visits. The New Jersey Department of Human Services provides an approved screening tool (Section B.4.9 of the managed care contract appendices) to be used on children when an indication of a potential behavioral health issue is uncovered.

Managed care organizations are required to notify families of upcoming well-child visits according to the state periodicity schedule. They are also responsible for conducting outreach to families if appointments are missed and notifying primary care providers when children are overdue for well-child visits.

New Jersey has in place a Medicaid medical home demonstration project. Managed care organizations (MCOs) are required to participate in the project, which includes the use of multi-disciplinary teams to coordinate care for Medicaid beneficiaries. The Medicaid agency provides flexibility in the payment methodology used by MCOs to support the medical homes but require that the MCOs “submit payment methodologies for review … that support care coordination and reward quality and improved patient outcomes.”

MCOs are also tasked with coordinating care and service delivery with a variety of community-based organizations and agencies, including:

State agencies, local health departments, Head Start and WIC programs;

Schools;

Social service organizations;

Consumer organizations, and

Civic/community groups.

MCOs must also maintain systems dedicated to coordinating physical and behavioral health services for enrollees.